FRONTLINE NEWS FOR KP WORKERS, MANAGERS & PHYSICIANS IN THIS ISSUE EVS injury rates plummet with safe and sane practices Pain, pain, go away: Hawaii nurses find secret to easing patients’ discomfort How unit-based teams improve clinical outcomes SUMMER 10 | ISSUE No. 24 How to get unit-based teams the support they need 2x2=8
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FRONTLINE NEWS FOR KP WORKERS,
MANAGERS & PHYSICIANS
IN THIS ISSUEEVS injury rates plummet with safe and sane practices
Pain, pain, go away: Hawaii nurses find secret to easing patients’ discomfort
How unit-based teams improve clinical outcomes
summer 10 | ISSUE No. 24
How to get unit-based teams the support they need
2x2=8
EDITOR’S LETTER
2 www.lmpartnErship.orgHank Summer 2010 | No. 24
Published by Kaiser Permanente and Coalition of Kaiser Permanente Unions
CommuniCations DireCtors
Maureen AndersonStacia Hill Levenfeld
eDitor
Tyra Ferlatte
Contributors
Kellie Applen, Cassandra Braun, Glenda Carroll, Paul Cohen, Paul Erskine, Tiffany Gardner, Jennifer Gladwell, Laureen Lazarovici, Julie Light, Anjetta McQueen, Gwen E. Scott, Beverly White
Worksite photos: Bob GumpertGraphic design: Stoller Design Group
3 2 x 2 = 8As unit-based teams hit critical mass, a new wrinkle is developing: How will
teams get the support they need with the resources available? San Diego and
Fontana have come up with facilitator pools; Colorado is taking that model and
tweaking it; Northern California has another approach. Find out what different
locations are doing to solve the equation.
6 KEEP IT CLEANEVS departments tend to be plagued by high injury rates—but teams in
Southern California and the Northwest are proving that partnership can make
the workplace safer.
9 PLAN, dO, STudY, ACT: PAIN, PAIN, GO AWAYThe Post-Anesthesia Care team wasn’t happy with the fact that only 60 percent
of their patients left their unit with “tolerable” pain levels. Using the Rapid
Improvement Model, they jumped that up to 95 percent. But how?
10 FROM THE dESK OF HENRIETTA: SMALL IS bIG Got a problem to solve? Don’t go getting all complex in trying to solve it,
says Hank’s resident columnist.
11 PHYSICIANS ON PARTNERSHIP: THE CASE FOR uNIT-bASEd TEAMS Looking for an improvement in clinical outcomes? Unit-based teams can get you
there, and this excerpt from The Permanente Journal explains why.
CONTENTS
Health care, it seems, is populated with perfectionists. That’s a good thing. Lab tests need to be read accurately; wrong information could be harmful. Correct, timely diagnoses can make the difference between life and death.
But a little lack of perfection here and there might be just what
the doctor ordered.
Perfectionists tend to be black-and-white, either-or thinkers.
Things are right or things are wrong. How something turns out
is either a success or it is a failure—as in, complete failure.
That often spills over into regarding the person associated with
that “failure” as a failure, too.
It’s time to introduce a few shades of gray.
The “tests of change” that unit-based teams conduct as part of
the Rapid Improvement Model (RIM) are mini-experiments. If a
test fails to produce the desired outcome, the failed experiment
needs to be considered an opportunity—not a failure. The team
has important information now that can be taken into account
when the next test is run. The only failure would be to not
incorporate that knowledge into the team’s work going forward.
And a failed experiment does not make a failure of the person—
or team—conducting the experiment. If it were otherwise,
then scientists would be failures many times over. One of the
activities that makes science science is running repeated
experiments to test the validity of different hypotheses.
Some succeed. Some fail. It’s all part of learning.
Our society at large, however, emphasizes winning, which makes
us collectively skittish about failing. We get into a habit of shying
away from trying out new things.
Many—perhaps most—of us don’t get good training on how
to systematically set up an experiment, run it, and then learn
from the outcome and apply what we learn to a next step.
We especially don’t get training in how to do that in a team.
That’s part of why, as the “2 x 2 = 8” story that starts on page
3 points out, a UBT’s ability to ask for and receive help can
speed it on its way to high performance. Different kinds of
help are appropriate at different stages in a unit-based team’s
development. Leaders everywhere are scrambling to be sure
that teams get the support they need to be successful.
Successful, that is, at perfecting their ability to learn from
imperfection.
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What is Hank?Hank is an award-winning journal named in honor of Kaiser Permanente’s visionary co-founder and innovator, Henry J. Kaiser.
Hank’s mission: Highlight the successes and struggles of Kaiser Permanente’s Labor Management Partnership, which has been recognized as a model oper-ating strategy for health care. Hank is published quarterly for the Partnership’s 120,000 workers, managers, physicians and dentists. All of them are working to make KP the best place to receive care and the best place to work—and in the process are making health care history. That’s what Henry Kaiser had in mind from the start.
For information about the manage-ment and union co-leads advancing partnership in your region, please visit LMPartnership.org.
Learning by failing
Cover story
www.lmpartnErship.org 3 Hank Summer 2010 | No. 24
(continues on page 4)
2x2=8
Supporting UBTs: UBT consultants and part-time facilitators gather at a San Diego planning meeting, including (left to right) consultant Sylvia Wallace, senior UBT consultant Jenny Button, Stephanie Densmore, and consultants Amy Steiner and Sue Smith.
Unit-based teams have hit critical mass, with some 86,000
workers in nearly 3,000 teams. There are hundreds of
examples of the great performance improvement work
that teams can do. But how will teams get the long-term
support they need with the resources available? How does
providing that support get integrated into the existing fabric
of Kaiser Permanente operations?
While the ultimate goal is to help teams advance their
problem-solving skills so they can lead their own performance
improvement efforts, many leaders agree there will be an
ongoing need to provide support—in some form—to UBTs.
“The worst thing we can do with the teams and individuals
is let them believe that training alone will help them get
better,” said Matthew Taylor, Colorado’s director of
performance improvement. “Training is the starting place.”
In facility after facility and across the regions, people are
developing different ways to provide the facilitation and
support teams need to take the concepts they have learned
in training and put them to use in their day-to-day work.
This has been particularly important in recent months,
with the double demand of launching the final wave of UBTs
while helping existing teams escalate their performance.
WE CREATED THEM. NOW WHAT? Some medical centers, like Fontana and San Diego,
have created facilitator pools—groups of employees trained
to support new UBTs through their beginning stages.
Northern California, meanwhile, has established “resource
networks,” made up of leaders and project managers at
a facility who have the subject knowledge and problem-
solving skills to transfer to teams.
TARGETED ASSISTANCE
At Fontana and San Diego, the pools of part-time
facilitators have been a big help in expanding support
for teams coming on line, providing guidance as they form
a charter or begin to use consensus decision making.
That allows the full-time consultants and subject experts
with extensive training in performance improvement to
focus on working with more advanced teams.
Jenny Button, the senior UBT consultant in San Diego,
says the part-time facilitators have provided invaluable
support for the UBT consultants as well as the teams.
“We’re not stretched as thin, because they’re taking on
teams,” Button said. Without the facilitators, “there would
be teams we (wouldn’t be) able to support as well.”
The part-time facilitators range from managers to medical
assistants. All have shown a knack for facilitation and
It’s a tricky juggling act—getting new teams off the ground while keeping others aloft and flying ever higher. Regions and facilities alike are inventing, stretching and adapting to make sure teams get the support they need to multiply their initial successes.
(continued from page 3)
problem solving—skills usually gained or demonstrated
through involvement in their own department’s UBT.
San Diego’s facilitator pool is modeled after one at Fontana
Medical Center, which created a pool—in 2005—to help the
teams coming on line there.
“The major role (facilitators) play is…to facilitate start-up
processes, coach and mentor co-leads and team members,
and help to transfer facilitation skills to the teams before
they leave,” said Kathy Brink, lead LMP consultant at
Fontana. That way, she says, “we’re able to work with
more teams at a time.”
BENEFIT TO TEAMS AND INDIVIDUALS
The facilitator pools help transfer and develop skills in more
ways than one—the teams benefit, and so do the part-time
facilitators. Many of them say the work has deepened and
broadened their own problem-solving skills.
“As a facilitator, I’ve learned so much about KP,”
said OB/GYN medical assistant Geraldine Lara, a member
of Fontana’s facilitator pool.
Lara underwent facilitator training in January 2009. She
works with teams over a period of six months, helping
them past initial communication, meeting and project
management issues.
“You ask them what they need to fix, so if they get
stuck you can throw out questions,” said Lara, who has
worked with pharmacy and engineering teams. “You
might not understand how a department works or know
the lingo, but you can help them brainstorm.”
Working with the UBTs, Lara says, has expanded her
problem-solving skills with her own unit.
But part-time facilitator pools, as much as they are help-
ing with the remaining wave of new UBTs, are not the full
answer to providing the long-term support teams need
as they accelerate performance improvement work.
“Many of our teams are well past the foundational steps.
It’s no longer just about creating a charter,” Button said.
“Now—how do you teach them to tackle those metrics?
First it’s low-hanging fruit, and then they need to get into
meaty stuff.”
To help teams do this, San Diego is turning to content
specialists—experts from various disciplines and areas
‘IT’S NO LONGER JUST ABOUT CREATING A CHARTER. NOw—HOw DO YOU TEACH THEM TO TACKLE THOSE METRICS?’
—Jenny Button, senior UBT consultant, San Diego
Helping others help themselves: Jenny button,
the senior ubT consultant in San diego, says the pool
of part-time facilitators gets ubTs the help they need
Mervin Francisco, both assistant department administrators; Miah Galindo, RN; Ruby Gill,
clinical director, Medical-Surgical/Telemetry; Jennifer Eusoof, assistant department admin-
istrator; and Christy Garcia, RN. Nanasca, Saberon, Jiyeon, Maan, Galindo and Garcia are
members of UNAC/UHCP; DelaCruz-Davis, Pelino and Nave are members of SEIU UHW.
Teamwork: Gary Kienbaum, the PACU and Surgery Center manager, talks with his labor counterpart, RN Ravida Benjamin, an HNA member (above right, left to right).
From the Desk of henrietta: SMALL Is BIG
10 www.lmpartnErship.orgHank Summer 2010 | No. 24
Including me. Even as I sat down to write this piece, I forgot the very thing I was trying
to remind all of us about—that small, simple approaches can, and do, have a big impact.
I proceeded to get bogged down in compiling numbers, culling examples and designing
an ambitious treatise to make my case. I froze, stumped, cursor blinking infuriatingly at
me for the next word.
Sometimes when we think big (which is not a bad thing, by the way) we can get tripped up,
tangled and strangled by monumental thinking. The vision turns into an unwieldy monster
we can’t begin to figure out how to start tackling.
The always irreverent writer Anne Lamott, who is quite familiar with how easy it is to
become overwhelmed by the “big,” said it best. You do it “bird by bird.” Sometimes you
tackle the monster small piece by small piece, small change by small change.
WHAT’S GOOD FOR THE GOOSE
You don’t have to strain your neck to see endless examples of teams that have seen
success with tiny tweaks, or in Kaiser Permanente parlance, “small tests of change.”
And they illustrate over and over again why small changes are an effective approach
to problem solving. They’re often easy, usually inexpensive and frequently require little
infrastructure. It’s an approach that works well for my hairstyle, too.
Here are a few examples of big improvements that came from small, simple tests of change.
In Fontana, the inpatient physical therapy department purchased inexpensive grease
boards of the type found at any office supply store, and posted them in patients’ rooms
to improve communication with nurses. The physical therapists needed a reliable way to
communicate to nurses the status of a patient’s mobility and the type of physical therapy
the patient was getting. From that small improvement, the rate of patient information
exchanged between physical therapists and nurses increased from less than 50 percent
in October 2009 to 68 percent in March 2010.
Let’s turn to another Southern California team. When the Internal Medicine team at the
Hill Road Medical Office in Ventura wanted to focus on helping patients control hyper-
tension, it turned to something simple: a bright yellow sign. The day-glo sign is posted
on the outside of exam rooms to remind physicians and staff members to repeat blood
pressure tests on patients who require them. If the first blood pressure reading is high,
the second test—which needs to be taken at least two minutes after the initial test—
helps accurately diagnose hypertension. Before the yellow sign, patients often left before
staff could take the second reading.
Before the team starting using the signs, the needed second blood pressure checks were
done only 26 percent of the time. Within one month of using them, the department was
giving the second test 100 percent of the time. (Read more about this team in “The Case
for Unit-Based Teams,” opposite page.)
A little farther south, at Rancho Bernardo Primary Care in San Diego, no test of change is
too small. And more often than not, the tests have met with success.
ELEMENTARY TRICKS
One small test included the use of paper clock faces with moving hands, the kind you
would use to teach a child how to tell time. A nurse on the primary care UBT suggested
they mount the clocks on the outside of exam room doors to help them cut down on
the amount of time a patient waits in an exam room before the physician arrives.
After taking a patient into the room, the medical assistant or licensed vocational nurse marks
the time the patient was “roomed” so they can monitor how long a member is left waiting.
“Anything longer than 15 minutes is unacceptable,” said Evelyn Bartolome,
Rancho Bernardo’s medical office administrator.
If a staff member notices a patient has been waiting longer than that, the person alerts
the physician.
“I haven’t received one complaint since we started these,” Bartolome says.
I could go on. But then I’d be guilty of making a simple point complex.
One last thing, though.
The beautiful thing about a small test of change? If it doesn’t work, you scrap it and move
on to the next little ingenious idea, and you keep trying until something sticks. And before
you realize it, your small tests of change will have become stepping-stones, leading you out
of a quagmire and closing in on success.
Small change isn’t just for the crevices in your couch. That’s one of my favorite sayings, and one I think we all can benefit from remembering.
Keeping it simple: The engineering team in Fontana found a solution to keep information flowing between shifts: a simple greaseboard where unresolved problems could be logged. Shown here, engineer Daryl Brothers, a member of United Steelworkers Local 7600.
‘If we want to optimize a system, it’s going to be around teams and teamwork.’
—Donald Berwick, MD appointed by President Obama to head the Centers for Medicare and Medicaid Services
The case for unit-based teams
Unit-based teams are transforming the KP workplace, step by step—but many physicians
wonder just how UBTs can help them get better outcomes for patients, improve their
department’s operations or enhance the patient care experience. An article in the Summer
2010 edition of The Permanente Journal, excerpted here, answers those questions.
A MOdEL FOR FRONTLINE ENGAGEMENT ANd PERFORMANCE IMPROVEMENT
ARTICLE BY
Paul M. Cohen, Mark Ptaskiewicz, MD, and Debra Mipos
New
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